Information Collection

Individual Questionnaire

IC 223311 under ICR 201608-0920-013 · OMB 0920-1137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1137 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Individual Questionnaire	Form and Instruction
Zika Investigation - Individual Interview Form SPANISH Att H - Individual questionnaire SPANISH.doc	Form and Instruction

IC Title:

Individual Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Zika Investigation - Individual Interview Form SPANISH	Att H - Individual questionnaire SPANISH.doc	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records Systems Notice

FR Citation: 51 FR 42466

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.